KHN’s Mary Agnes Carey talks to Andy Allison, Arkansas Medicaid director and president of the National Association of Medicaid Directors, who is adamant that cash-strapped states won’t be able to do much to expand coverage to the uninsured if the Supreme Court strikes down the law. States are expected to add 16 million people to Medicaid, but that’s mostly because the federal government would pick up nearly all the cost. Allison said, “I’m not sure where those individuals will end up now, with money so tight” in the states.

Read an edited transcript of the interview:

ANDY ALLISON: This uncertainty that states have faced has really slowed implementation. So I think states will be facing a real choice, if the Supreme Court were to uphold the Medicaid expansion in June or July this summer, to move forward despite what is likely to be continuing political opposition, because it really is impossible to implement the bill if you don’t operationally begin to put those systems in place beginning this summer.

I think also there are a number of policy choices that were left to states. The Senate bill won out in the debate over the Affordable Care Act, and so many states really haven’t made those important policy choices about how their health insurance markets will work, how Medicaid will be expanded, what it will look like. And so I think later this summer, we’ll see push come to shove, and states will need to decide whether to move ahead even if there’s future political uncertainty over the bill.

MARY AGNES CAREY: What about some of your members that are in states where either the governor and/or the state legislature has been adamantly opposed to the health law? Have their hands basically been tied and are they really going to be behind the eight ball if the law is upheld?

ANDY ALLISON: I think there are some states around the country where the program’s hands have been tied. That’s not a secret. That’s a very public and open discussion at the state level. And many state legislatures have considered bills to make implementation a crime, so it’s a very common debate, and I hear very commonly from Medicaid directors that they really haven’t been able to do much. So again, a choice is coming this summer, if the bill is upheld, where those governors and those legislatures and those Medicaid directors will need to make what could be some pretty hard choices.

MARY AGNES CAREY: But even for states where Medicaid directors have been able to move ahead, you mention operational challenges. How many states won’t be ready starting in the fall of 2013, early 2014, to get people enrolled, to determine their eligibility? These are very complex systems.

ANDY ALLISON: I don’t know how many states won’t be ready. I think the possibility exists that all states could be ready. In order to become ready in such a short amount of time — now even shorter than the original window of 3 to 3 ½ years when the bill passed — in order to reach that goal of Oct. 13 to begin enrolling individuals and Jan. 14 to actually cover them and reimburse for services, a lot of things will have to change. We’ve talked about the political environment to allow for policy decisions and operational progress to be made — and then somewhat of a moonshot effort to actually achieve that target next year and maybe a new level of cooperation between states and the federal government, operationally, to make it happen.

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